Generalizations: General Internal Medicine Board Review

1. Generalizations:General Internal Medicine Board Review Jimmy Stewart, MD Professor of Medicine and Pediatrics Division of General Internal Medicine and Hypertension Program Director, Med/Peds Program University of Mississippi Medical Center

2. Preventive Medicine • Screening • Vaccinations • Prophylaxis • Education

3. Colorectal Ca • All adult ages 50-75 yo • 40+ or 10 years prior to relative • FOBT, flex sig for “average risk” • Colonoscopy - every 5-10 years for high risk

4. Prostate Ca • PSA - NOT recommended for routine screening • Greatest sens in AA or high risk group

5. Lipids • High Risk (CAD or equivalent) – statin • LDL > 190 mg/dL – statin • ASCVD risk > 7.5 % - statin

6. Attenuated Live Vaccines • MMR* • Oral Polio • Nasal influenza • Yellow fever • Smallpox • Typhoid • BCG • Varicella (including Zostavax)

7. HIV vaccinations • HBV • Influenza • Pneumococcal • Hib • MMR/Td

8. Strep Pneumo • Asplenia • >65 yo every 5 years • Chronic disease (including DM)

9. Influenza • Yearly >50 yo • Healthcare workers • Childcare workers • Household contacts of above

10. Zostavax • >55yo? • History of zoster not important

11. Others • Meningococcal - not against “B”, college freshmen • Cholera - DOESN’T WORK

12. Traveler’s diarrhea: Prevention • Flouroquinolones • Azithromycin • Must take daily

13. Traveler’s diarrhea • Mild: 1-2 stools/day - loperamide • Mod: 3 stools/day - single dose Abx • Sev: 6 stoos/day - Abx x 3 days with loperamide

14. Traveler’s diarrhea: Treatment • Flouroquinolones • Azithromycin

15. Malaria • Chloroquine-resistant - Mefloquin (neuro SE’s) • Chloroquine • Others - doxy, primaquine, azithromycin

16. Gray - resistant; Blue - sensitive

17. Meningococcal • Rifampin • Cipro • Rocephin - pregnancy

18. Education - what works... • Smoking cessation • Firearm safety • Bladder Cancer • Folate supplementation • Osteoporosis • CVA

19. Drug Overdose • Isopropyl (rubbing alcohol) • Methanol (wood alcohol) • Ethylene Glycol • Salicylates • Acetaminophen • Theophylline • Lithium • Tricyclics • PCP • Anticholinergics • Cholinergics • CO • Cyanide • Pb • Insecticides

20. Isopropyl • CNS depression • Osmolal gap • Early lavage • Hemo/peritoneal dialysis

21. Methanol • Visual changes • AG met acidosis • Treat with ETOH, folate, dialysis, fomepizole

22. Ethylene glycol • Ca oxalate crystals • AG met acidosis • Treat with ETOH, bicarb, calcium, dialysis, fomepizole

23. Calcium Oxalate: “folded box”

24. Salicylates • AG met acidosis • Classic presentation: AG with pH 7.4 and history • Treatment - lavage, alkalinization, hemodialysis, charcoal

25. Acetaminophen • N - acetylcysteine • Early gastric emptying • Normogram

26. Theophylline • Seizures • Treat with diazepam, lavage, charcoal, cathartic

27. Lithium • MS changes, Parkinsonian • DO NOT GIVE CHARCOAL • Lavage, electrolytes/fluids, hemodialysis

28. Tricyclics • Tachycardia, long QT, PR, QRS • Hemodialysis INEFFECTIVE • Alkalize • Lidocaine/phenytoin

29. PCP • Agitation, seizures, dystonia, HTN • Give ammonium Cl to acidify the urine • Diazoxide for HTN

30. Anticholinergics • “Red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare” • Supportive care • Physostigmine

31. Anticholinergics • Scopolamine • Antihistamines • Antipsychotics • Antispasmotics • Cyclic antidepressants • Mydriatics

32. Cholinergics • “SLUDGE” • “DUMBELS” • Skin cleansing • Atropine • 2-PAM for organophosphates

33. Carbon monoxide • CNS depression • mild-mod: 15-30% • mod-sev: >30% • Fatal: >50% • O2

34. Cyanide • Almond breath, bright red venous blood • Amyl nitrate • 3% Na nitrite • Sodium thiosulfate

35. Ethics Principles • Autonomy • Beneficence • Nonmaleficence • Cultural differences • Confidentiality • Brain death - NO EEG REQUIRED!

36. Perioperative Evaluation • Clinical Risk • Functional Capacity • Risk of Surgery

37. Clinical Risk • History • PE • ECG (men >40 yo, women >55 yo, CAD)

39. Functional Capacity • Excellent: >7 METs • Moderate: 4-7 METs (angina walking >2 blocks) • Poor <4 METs (angina walking 1-2 blocks)

40. Surgical Risk • Low - endoscopy, local biopsy, breast biopsy, vasectomy, cataract • Mod - CEA, intraperitoneal, intrathoracic, orthopedic, prostate, head and neck • High - emergencies, long procedures/fluid shifts, CVS (cross-clamping aorta or bypass

41. Who to Test? • Moderate risk with poor functional capacity • Moderate risk with good functional capacity and high risk surgery • High Risk - all

42. Tests • Exercise stress treadmill • Dipyridamole thallium • Dobutamine stress echo

43. Scenarios... • Low risk patient goes directly to surgery without testing • Moderate risk patient with good functional capacity goes directly to nonvascular surgery • High risk patient need further workup

44. Ophthalmology • Glaucoma • Retinal Detachment • Retinal Vascular Occlusion • Optic Neuritis • Vitreous Hemorrhage • Alkali/Trauma • Iridocyclitis • Keratoconjunctivitis • Viral conjunctivitis • Bacterial conjunctivitis • Neisseria conjunctivitis • Endophthalmitis

45. Closed Angle glaucoma • Asian American with severe acute nausea, headache while in movie theater • Ocular emergency • Pupillary constriction

46. Retinal Detachment • Acute trauma to head/globe • Flashes/streaks of light, showers of black dots • Ocular emergency

48. Retinal Artery Occlusion • Sudden, PAINLESS BLINDNESS • Mostly embolic • Ocular emergency

49. Optic Neuritis • Ocular pain with eye movement, loss of vision • MS

50. Vitreous Hemorrhage • Sudden painless loss of vision • Must look for retinal detachment